Reference no: EM133343978
Case Study: Muscle Tenderness
Subjective:
Carmen is a 32-year-old female who reports tenderness when anyone or anything touches her. She has experienced these myalgias throughout her body for the last 6 months, and the pain is affecting her quality of life. She describes the pain in the back of her head her neck, her upper chest, upper back her elbows, backside, and knees. The pain occurs on both sides of her body. "My joints feel swollen, and my skin burns." She feels profoundly fatigued and yet is unable to get a full night's sleep. She has trouble falling and staying asleep. She finds that she is often irritable, and this is affecting her relationships. She denies fever, chills, nausea, vomiting, and diarrhea. She denies changes in her hair, skin or nails or ay change in her menstrual period, which occurs every 28 days and last 5 days. Her last LMP was 3 weeks ago. She had unprotected sex 2 weeks ago with an old friend who consoled her after her move here. She denies any joint pain, dry eyes, dry mouth, ulcers, rashes, lesions, or morning stiffness.
Past medical/surgical history: Hypertension that is controlled; irritable bowel syndrome; and appendectomy at age 14.
Social history: She moved to this state 2 months ago and has been given opioids by her previous primary care provider. These helped moderately, she would like some more. "At least they help me get some sleep." Carmen divorced her husband, prompting the move out of state; she moved her with her two teenagers who are getting into trouble and are confused by the recent changes in their lives. Carmen admits to feeling sad often but denies suicide ideation. She often feels unfocused and unable to concentrate. She denies use of tobacco, alcohol, and recreational drugs. She has worked since age 15 and currently works in the school cafeteria so she can be around her children and be home when they come home. She receives some financial assistance from her husband.
Family medical history: Mother had rheumatoid arthritis. Father died of colon cancer at age 65 years.
Medications: Lisinopril 10 mg; Percocet 10/325 mg every 6 hours as needed for pain; MVI. The patient has been out of Percocet for 4 weeks.
Objective: Height 5 ft 3 inches; weight: 150 pounds; temperature: 98.7 F oral. HR is 68 and regular. RR is 12 and regular. BP is 124/70
General: Teary; appears anxious
HEENT: Head: normocephalic, mild tenderness to palpation (TTP) of occiput. Eyes: PERRLA, EOMs intact. Nose: No polyps, no erythema. Mouth and throat. No oral ulcers, erythema, no exudates; tonsils are +2. Neck: TTP, LROM on rotation due to pain; thyroid is nonpalpable.
Cardiac: S1/S2; RRR without murmurs, gallops, clicks, or rubs
Lungs: clear to auscultation bilaterally
Abdomen: Soft, no bruits; positive for bowel sounds; non-tender; non distended. No organomegaly.
Neurologic: Mentation grossly intact; CNs II-XII grossly intact; DTRS +2 UEs and LEs; negative Romberg; negative RAMs; proprioception and sensation grossly intact.
Musculoskeletal: Using 4g of pressure, the pain was elicited from the cervical spine, trapezius muscles bilaterally, just below the clavicle (2nd rib) bilaterally; elbow bilaterally, gluteal, and knees. There is FROM, and strength is 5/5 throughout. There is no synovitis, and there are no effusions
Skin: No rashes or lesions
Questions: Critical Thinking
Which diagnostic or imaging studies should be considered to assist with or confirm the patient's diagnosis?
What is your rationale?
What is the most likely differential diagnosis and why?
What is the plan of treatment for this patient and what is your rationale for implementing it?
Is there any referral that is needed?